0277-9536/92 $5.00 + 0.00 Copyright 0 1992 Pergamon Press Ltd

Sot. Sci. Med. Vol. 35, No. 4, pp. 5lS523, 1992 Printed in Great Britain. All rights reserved

SECTION K NEW PARADIGMS

FOR REFUGEE

HEALTH

PROBLEMS

MARJORIEA. MUECKE Department of Community Health Care Systems SM-24, University of Washington, School of Nursing, Seattle, WA 98195, U.S.A. paradigms that have shaped our understanding of refugee health are indentified: the objectification of refugees as a political class of excess people, and the reduction of refugee health to disease or pathology. Alternative paradigms are recommended: one to take the polyvocality of refugees into account, and one to construe refugees as prototypes of resilience despite major losses and stressors. The article is organized into three sections, mirroring the life history of refugees from internal displacement in the country of origin to asylum in a second (usually neighboring) country, and for some, to permanent resettlement in a third country. In each of the three sections, the primary topics that are treated in the literature are identified, and key problems identified for discussion.

Abstract-Two

Key

words-essentialism,

resiliance, women, post-traumatic stress disorder

In the past 5 years the world-wide refugee population has almost doubled to some 17 million; traditional donor countries have reduced their contributions to refugee protection and assistance; and established countries of asylum and/or resettlement have narrowed their doors of welcome. The ‘refugee problem’ began in this century as a matter of European and White Russians fleeing during a world war and/or from political persecution into neighboring countries until it was safe for repatriation or they made a home in a new country. The ‘refugee problem’ at the end of this century is a matter of massive flows of destitute people from Third World countries mostly within or to other Third World countries. Third World refugees are created by and dependent upon the dictates of transcontinental political-economic relationships for assistance and protection. The paradigm of refugees as political and poverty class of excess people has preempted alternative models. But recently our understanding of refugees has begun to expand through a new social science literature that is dedicated to refugee issues [l]. New schools of thought, critical and feminist, that argue for the interrelatedness of politics and emotion, for the agency of the oppressed, and against essentialist assumptions of structural-functional and positivist biomedical interpretations inform my discussion of refugee health and social problems. This survey of refugee health and social problems is organized into three sections, mirroring the life history of refugees from internal displacement in the country of origin to asylum in a second (usually neighboring) country, and for some, to permanent resettlement in a third country [2]. In each of the three sections, the primary topics that are treated in the literature are identified, and key problems discussed.

Repatriation, an alternative solution to asylum, is excluded due to the lack of coverage of the health and social situation of repatriated refugees in the literature. INTERNAL

REFUGEES

There is a class of people who do not qualify for the assistance and protection sanctioned for refugees only because their flight from persecution did not take them across an international border [3]. There is as yet no systematic formal procedure for recognizing or responding to these people-‘internal refugees’who are ‘internally displaced’ due to fear of persecution or gross violation of their human rights. The plight of internal refugees is muted by the world’s political agendas and by the sanctity of the principle of the sovereignty of the nation state. Individual governments or outside forces that undermine the power of a legitimate regime (as with RENAMO in Mozambique, the United States in Nicaragua, Indonesia in East Timor) systematically terrorize, displace and kill classes of people who cannot leave their own countries [4]. United Nations agencies and many government groups find themselves too constrained by formal definitions and mandates to respond [5]. Since no agency has the capacity or responsibility for tracking internal refugees, and since information on them is fragmentary at best, assessments of their numbers are highly variable yet always under-estimated. At the close of 1990, the U.S. Committee for Refugees estimated a minimum of 20 million internally displaced civilians around the world [6]. Recent rethinking of the issue in Africa suggests that this total is a gross underestimate [7’J. 515

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The reasons for considering internal refugees in this review are their appalling numbers-over twice as many more than bona fide international refugees; their life-threatening and often traumatizing situations; and the fact that most international refugees were internal refugees prior to their flight to asylum in another country, so carry a history of displacement and its meaning for them into asylum and resettlement. Medical problems of internal refugees are public health problems are political problems

Internal refugees are hidden from view of most western health care providers and consequently from western medical and social science literature as well. The medical problems of internal refugees typically are severe and prevalent: infectious disease, malnutrition, and war injury, these sometimes presaging systematic genocide [g-lo]. Malnutrition tends to increase in severity and prevalence with time due to consumption of scarce local resources and to inadequacies of international aid [l 11. Internal refugees may be cut off from international food and other aid by oppressive regimes, as in Ethiopia and El Salvador. But the international aid infrastructure itself apparently has too often failed in coordinating requisite public health assistence [12, 181. There are two predominant models for the provision of health care among internally displaced populations, population-based and problem-focused. A population approach to preventive health care [ 131 is a high priority of socialist liberation regimes that harbor internal refugees such as Cuba [14-161, Eritrea [17, 181, Mozambique [19,20], Nicaragua [21-231, Vietnam [24]. There is some evidence that the results of this broad-based approach to public health are remarkably resistant to destruction. Given the widespread prevalence of malnutrition and infectious disease among internal refugees, the population approach to health care is probably essential. The problem-focused model, in contrast, is typical of the health care of military campaigns and of many international donors. Its ‘vertical’ programs such as disease-specific immunizations generally are successful only in the short term. Although they may reduce cause-specific mortality by selectively targeting specific problems such as infantile diarrhea, they appear ineffective in promoting health 1131. Who should be left out when goods are limitedanyone?

Most of our medical knowledge about displaced peoples is specific to women of reproductive age and children partly because of their high nutritional needs and because of the high priority that emergency service organizations place on food distribution. Illness-related mortality is high for displaced populations in general, but it is particularly excessive among children under 1S years of age [2S]. Displaced elderly, in contrast, are particularly understudied

among this understudied population. One study of Tigreans displaced from Ethiopia to Sudan found that more than half of those aged 60 and over had been left behind in Tigray. Those elderly who fled to Sudan had high levels of minor disability, social isolation, and total economic dependency, but were excluded from health care plans because they were not among those segments of the population targeted for assistance [26]. So little is reported on internal refugees, even retrospectively, that we remain truly ignorant of the dilemmas that different groups within any country might face, of the various ways refugees muster resilience, and of the vagaries of survival. Living in the path of torture or terror

A large proportion of internal refugees live and die in war environments and/or contexts of terror and torture. The literature on trauma and torture survivors has burgeoned in the past few years, as it did after the end of the Holocaust. There are two types of author; one who has her/himself lived through the terror-the ‘experienced author,’ and one who has attempted to comprehend the suffering of the former. The latter are beginning to find, through retrospective case study, that sexual violence against female adolescents and women and head injury are much more prevalent among refugees than previously appreciated [27]. The ‘Experienced authors’ have recently directed our notions of mental health on a new trajectory. They find, as Farias [28] says, “the traditional theoretical understanding of the processes of trauma and migration, framed by notions of stress, resilience inadequate and even irrelevant and adaptation” because it “does not take into account the dialectical relation between the socio-political processes of terror and intimidation, the social conditions of marginality and illegality, and the emotional responses of individuals.” The thrust of this new direction has evolved in Latin America where mental health professionals have had extensive personal and professional experience with emotional responses to state terror. MartinBat-o, a foremost Salvadoran psychologist dedicated his career and life to clarifying the socio-political nature of trauma in El Salvador and to showing that it creates a collective experience of anxiety, terror, and denial of unacceptable reality [29]. Suarez-Orozco similarly describes the cultures of terror in Argentina, Nicaragua, El Salvador and Guatemala [30], and a volume edited by Riquelme [31] points out the need to validate patients’ experiences of state-induced terror as part of the healing process. Lacking the personal experience of living within a terrorized society, mental health professionals of developed countries have focused upon the individual psychodynamic processes of grieving and adaptation in their patients [32], and in the process, apparently missed the point that refugees’ socio-political context has been profoundly and pervasively transformative for them.

New paradigms for refugee health problems

Jenkins is a refreshing exception. She worked as a health care provider in El Salvador for 3 years, and on her return to the United States, undertook an ethnographic-clinical study of 20 women who had fled political violence, domestic violence, and/or economic poverty in El Salvador. In this study Jenkins identifies “distinctions between terror and torture, [and between] distress and disease. . . as essential to an account of refugee experience” [33]. She explains terror as an affect purposefully constructed by the oppressive state as a means of social control. She finds that long-term exposure to terror in one’s society renders the experience of “the lived body” one of distress and despair. Forced relocation is another state strategy of oppression. The strategy originated in the United States’ attempt to win the Vietnam War by removing places where guerrillas could hide. Civilians are forced into ‘strategic hamlets’ where they can be ‘protected’ from rebels while also being controlled by the government. In El Salvador the mortality rate of the displaced is 3.4 times higher than among the general population. But malnutrition is highest among that 43% of the displaced who are ineligible for food rations because they have not yielded to government relocation programs [34]. Thus, displacement itself is a multifaceted phenomenon that varies by situation. A recent study by Hourani et al. [35] shows that the experience of displacement may be a more useful indicator of its health effects than the fact or purpose of displacement. The researchers assessed the psychological effects of war on 5788 displaced vs non-displaced Lebanese by using a checklist of symptoms of distress. They found that social integration/social isolation was more profound than physical displacement in the Lebanese perception of psychological distress during war. Health care complicity in the conduct of terror

Health care may be treated as a military or guerrilla target during civil war. Violence against health care personnel and sites is a political strategy to instill fear in the populace, to penetrate everyday life with oppression, and to deprive the people of recourse when ill and wounded. Cases of this are documented for Cambodia [36], El Salvador (20,261, and Nicaragua [37], among others. Oppressive regimes may also compel health care personnel to use their skills to disable and torture the people [38-40]. Although professional complicity i.1 the perpetration of torture [41] by repressive regimes is best documented for physical torture in Latin America [42] and in the Holocaust [43], it occurs elsewhere. For example, physicians and nurses have reported that sterilizations were systematically performed on women without their informed consent as a means of population control in Zambia, Angola and in SWAP0 refugee camps in Namibia

WI.

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Problems pertaining to the understanding of internal refugees 1. How can access to internal refugees be increased for the provision of protection and public health assistance, and for research? Even if access were sanctioned through a revision of international codes, permitting exceptions to the principle of national sovereignty, who would pay for the assistance? Who would provide it? How can the mandates of health and social welfare oriented nongovernmental organizations (NGOs) be expanded to include assistance to internal refugees? Is defense of the basic human rights of internal refugees of sufficient value to garner the necessary political and economic support to ensure those rights? What is the responsibility of social scientists and health professionals who have access to these hidden people for making their observations known-to the academic community, to policy makers, and to the general public? 2. How can the principles of population-based or primary health care be implemented in countries that harbor internal refugees? Local-level community organization is imperative for long-term survival in situations of chronic displacement, yet community organization is incompatible with oppressive regimes’ need to maximize their control. 3. What can be done to protect health care workers from being co-opted into complicity with an oppressive regime to terrorize the populace or harm individuals? Whose responsibility is it when a health care worker is compelled by a government or military force to violate the codes of her/his progession? 4. What therapeutics can be effective with survivors of torture or terror? To what extent can mental health professionals who are inexperienced in distress and terror act therapeutically with survivors of torture? 5. To what extent do racist and classist values discriminatively inform international efforts to access internal refugees with assistance? Sub-Saharan Africa, for example, harbors uncounted millions of displaced persons, and over half of its refugees are under 16 years of age, yet it is left alone to a greater extent than other regions by the international community to address its refugee problems. Its lack of economic and political interest to the international community walls it off from significant assistance from the outside world. REFUGEES IN ASYLUM

The path from internal displacement to asylum [45] in another country is fraught with health risk and uncertainty. In getting to asylum, refugees may have to dodge military or guerrilla surveillance, sea pirates, or land mines: survive on wild foods while travelling through unfamiliar terrain at night to escape detection; and pay middle persons for protection or transportation along the way. That fraction who manage to attain recognition as refugees in asylum thereby

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win international assistance, highly variable degrees of physical protection, and a life style of dependency upon their hosts. Women are at special risk both during flight and in asylum because of the dependency of children and the sick and disabled on them, and because of their vulnerability to sexual exploitation. Enforced dependence of refugeer in asylum

The international aid community is a separate class from the refugees in asylum that it serves. The extent to which aid organizations and governments deprive refugees of control over their own lives became a compelling subject in the refugee literature of the late 1980s. Refugees have been systematically although implicitly excluded from decision-making that affects their lives at both the levels of policy and operations. This oppression in the guise of service is forcefully demonstrated by Harrell-Bond [46] in the case of emergency relief activities, and by Tollefson [47] and Mortland [48] in educational programs that prepare refugees for resettlement in a third country. The challenge now is to transform recognition of the need for refugee paticipation in decision-making regarding them from ‘buzz-word’ into normative practice. Refugee women in asylum as ‘a particular group’

Programmatic and academic recognition that women refugees have distinctive health characteristics has been grounded in and largely limited to an obstetrical definition of women’s health. For example, in a review of the literature on the health status of Southeast Asian refugee women, Kulig [49] found that the majority of the 88 articles she identified focused upon the women’s childbearing role, while the remainder treated issues conventionally defined as women’s, such as childbearing and healthillness beliefs. This focus is misleading for two reasons: it defines women only in terms of reproductive capacity, and it ignores the impact of gender as an organizing principle of life in asylum. According to Indra [50], the focus excludes “how gender relations structure refugee lives and the administration of humanitarian assistance” from examination and from assistance policies. An essentialist definition of ‘The Refugee’ as either ungendered or as male has eclipsed women from consideration and participation in protection and assistance policies and programs 151-521. Inquiry into the meaning of being a woman refugee is a small but growing area of refugee studies, policy and programs. There is a recent and growing groundswell of opinion that because of their sex-linked exclusion and exploitation, refugee women in asylum should be considered ‘a particular group’ to whom the UNHCR definition of refugees applies. In the past few years, the Executive Committee of the UNHCR has issued a number of Conclusions on the International Protection of Refugees that prescribe a variety of measures that advocate for refugee women. These measures

would protect refugee women from assault; support the equality of their rights to those of refugee men; provide for the care of abused women; and enable refugee women to participate in decision-making regarding how they lead their lives [53-541. Grounds for these measures include women refugees’ particular risks and responsibilities. Their risks as a group include the risk of rape; of being constrained to practice prostitution to secure survival and basic amenities for herself and family; of exclusion from training, literacy or other development programs. Their special responsibilities are for nourishing and protecting the dependent, the aged, children and the sick and disabled, and unemployed men. Risk of rape tends to be a feature of refugee camp life for women refugees, especially when the camps are in an area of political unrest or are monitored by host government military. Because widows and fartherless single women ‘belong’ to no man, they are especially vulnerable to rape: other men may consider them ‘fair game.’ Rape of refugee women exploits and abuses not only the individual woman but also is a type of persecution that is based upon the group characteristics of refugee women [55, 561. Inter-group rape, as between different political factions who have fled the same country (as the Khmer Rouge and the Khmer Peoples National Liberation Front from Cambodia), or as between host country ‘guards’ and refugees, has the effect of humiliating the violated women’s husbands, fathers and brothers, and community: the assault demonstrates their ineffectiveness in protecting their own kin and kind. The rape and prostitution of women refugees must be seen as a political phenomenon as well as acts of interpersonal aggression: they are means of demonstrating intergroup power differentials and of ensuring the oppression of refugees as a class of human beings. Coping with chronic asylum

There is a strong tendency among international aid groups, the news media and governments to focus selectively on the initial crisis stage of asylum. At that time, aid programs tend to define refugees as masses of people with acute and tangible needs that can be addressed with material goods and services, including shelter, food, and emergency health care. Some threequarters of refugees, however, are in asylum for more than 5 years. The health and resilience of refugees in chronic asylum are areas about which we have truly limited understanding. Given the chronicity of a growing number of mass asylum situations (as of Palestinians, Cambodians and Afghans), more studies in particular are needed of the longterm effects of chronic asylum on children. A recent study of Palestinian children aged 8-14 found a direct correlation between exposure to political hardships and psychological symptoms that was unaffected by the way the children tried to cope [57]. A study of Vietnamese children in Hong Kong camps suggests that family and community cohesiveness

New paradigms for refugee health problems may partially protect children from fears associated with the witnessing of violence [58]. What happens to the millions of asylum children whose families are fractured or whose communities are riddled with survival-oriented mistrust is not known. Unaccompanied refugee children, those who are separated from the adults (family) who customarily would provide nurturance and protection for them, have been recognized programmatically as having distinctive needs in many long-term camp situations [59], but we are ignorant about how best to provide for their reintegration into close personal relationships. Problems pertaining to the understanding of refugees in asylum

There are serious barriers to the conduct of research among encamped refugees. And there are large and critical arenas of ignorance and partial understanding relating to refugees in asylum. The following is not an inclusive list. 1. Research access to refugees in asylum is seriously impeded by host government needs for security and control, and this may be compounded by territorialist competition among assistance agencies in the camps. 2. The ethics of studying refugees in asylum is problematic because of the difficulties in avoiding coerced participation, in providing for consent that is truly informed about the possible risks of participation, and in preventing the formulation of false expectations. 3. Data on refugees are collected by assistance agencies, but since they were gathered for operational rather than research purposes, they lack the precision required of research and they reflect the particular interests of the agency that collected them. 4. The inherently political nature of encamped refugees and of their relationship to authority figures jeopardizes the validity of research findings. Impression management by refugee camp staff or agency is expectable and could bias findings or interpretations in perhaps unknowable directions [60]. 5. How and under what conditions assumptions about gender relations inform refugee assistance and protection policy is a new area of inquiry that urges reconsideration of the bureaucratic structures for refugee aid. The reconsideration could undermine the legitimacy of customary programs and powerholders. The debunking of tradition that protects the power interests of a particular group could require revolutionary thinking. 6. Longitudinal studies that link asylum experiences both to pre-flight triggers or resources, and to post-resettlement outcomes are needed in order to develop better understanding of refugees as human beings whose lives are continuous despite major discontinuities in their life experiences. The only type of longitudinal perspective apparent in the literature is retrospective in nature, and reflects back from the perspective of permanent resettlement. SSM 35,4--L

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REFUGEES IN RESETTLEMENT

The primary good that we distribute to one another is membership in some human community. Michael Walzer, Spheres of Justice 1983 Resettlement is one of three ‘permanent solutions’ to the dilemma of being a refugee, all of which restore legal membership in a state to the refugee. The other two solutions-repatriation and permanent settlement in country of asylum-are preferred if feasible and safe because their cultural and territorial dislocation are not as totalizing as in third country resettlement. Worldwide, these two solutions are many times the more common than permanent resettlement in a third country. Nevertheless, almost all the literature on refugees who experienced these permanent solutions pertains to resettlement. This no doubt reflects the ready access that researchers, most of whom are ‘western,’ have to resettled refugees, since resettlement occurs almost exclusively in western countries [61]. The issues discussed in this section all pertain to a reductionist interpretation of refugees. The first two issues examine the reductionism in a strictly medical interpretation of refugee health and in a reification of psychiatry through the diagnosis of post-traumatic stress disorder (PTSD). The last issue reviews alternatives to a reductionist interpretation of refugees that is proposed by critical and feminist theory. The objectiJcation of refugees as a medical phenomenon

Only in the past 20 years has resettlement involved transcontinental moves of masses of human beings of radically different cultural orientations [62]. For the first 10 or so of those years, service providers in refugee receiving countries were unfamiliar with the refugees’ languages and social and political backgrounds. Host governments’ first health concern was protection of the host population from diseases that refugees could import. This is documented in the types of service provided and in the spate of articles on contagious and ‘rare’ (for the temperate climates of western nations) tropical diseases. The preoccupation with disease pervaded refugee-related policy, program development and research. It curtailed the spread of tuberculosis and prevented the emergence of immunizable diseases, and it had unplanned effects that continue to haunt the health picture of resettled refugees today. The unplanned effects include a medical definition of the refugee, such that medical problems became the primaty route for refugee recourse when in any kind of pain, whether medical, social, or emotional. In the United States, medical opinion and diagnoses have determined eligibility for special economic benefits. Refugees were classed rather than personalized in the health and social service programs and literature. They were classed as foreign, dependent and poor, and in need of (only entry level) jobs and of

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health care. Health care providers did what they do best and provided physical assessment, diagnosis and treatment, and published the medical findings. As the initial phase of transcontinental resettlement passed, it became clear that a disproportionate number of refugees had intractable medical problems. These tended to be interpreted and diagnosed as somatic expressions of emotional pain, particularly among refugees from Southeast Asia [63-66]. This interpretation was reinforced by the recurrent finding that refugees ‘underutilized’ mental health services [67,68]. However, there were almost no mental health programs specifically designed for refugee groups, suggesting that medicineand agency-serving assumptions in health care reduced the persona of refugees to physical bodies in need of repair. Refugees were so objectified by this perspective that their suffering and manifestations of emotional distress were fundamentally overlooked [69]. Reductionism of the post -traumatic stress disorder (PTSD) diagnostic label Since 1984 the refugee health care focus has shifted to the post-traumatic stress disorder (PTSD), delayed or chronic type [70-711. In North America this work and its concurrent new emphasis upon the psychological sequelae of trauma among refugees has been spearheaded by a handful of university psychiatric clinic-research groups that specialize in the assessment and care of refugees from Indochina: Oregon Health Sciences University [72-741; Harvard Medical School [75,76]; the University of British Columbia (Vancouver) [77-791; and the University of Minnesota (with the Hmong) [8&83]. Such centers for the care and study of refugee mental health have increased refugee access to mental health care and have permitted their long-term follow-up and support [84,85]. The centers have enabled the development and testing of easy-to-administer instruments for culture-sensitive, language-appropriate screening of mental health among Indochinese refugees [86-881. The centers have also given some voice to the ineffable experiences that refugees carry indelibly with them. The question raised by the clinician-researchers is whether, due to the highly traumatic nature of the recall and relating of experiences with trauma, giving voice to that experience is therapeutic or iatrogenic. There is a growing body of clinical evidence that the detailed retrospective inquiry characteristic of psychiatric therapy is associated with a disturbing intensification of symptoms [89]. The durability of any reduction in symptoms that may be associated with other psychiatric interventions such as the use of tricyclics or therapy that supports the avoidance of past events is not known. The PTSD diagnostic label has helped focus clinical and research attention upon the mental health needs of refugees after their resettlement. This has enabled the awareness that with time, psychological difficulties may increase rather than taper off among

certain groups of resettled refugees, particularly the unmarried or otherwise unattached [75,90]. For example, a recent study of 50 Cambodians resettled in the U.S.A. who were randomly selected from the general, non-patient, population found that 86% met DSM-III-R criteria, for PTSD, and 80% were suffering from clinical depression [91]. While having PTSD as a diagnostic assist no doubt has empowered clinicians by giving them the sense that they know what they are dealing with clinically, the label has yet to lead to cure or even palliation of the profound distress with which many refugees live. The widespread utilization of the PTSD diagnosis can thus be seen as perpetuating the reductionism of psychiatric categories. It sanctions continuing neglect of refugee suffering, suffering that is associated not only with the experience of persecution and trauma, but with the stigma, isolation and rejection of being irretrievably out of phase with the host society and its values, and with one’s parents’ generation and with the generation of one’s children. Medicine and psychiatry cannot take account of or redress suffering of this magnitude, depth and complexity because they both are grounded in the assumptions of the inviolate primacy of the individual and of the necessity of treating the patient instead of the environments that constrain patients. Furthermore, medicine like all our helping institutions, tends to be riddled with the racist, sexist and classist values of larger society, and to the extent it is, contributes to the distancing of refugees as a class of people. Finally, because the existence of both medicine and psychiatry is predicated upon the necessity of pathology or problems, they cannot take primary account of the strengths and resilience of refugees. Refugee resilience The data and conclusions about refugee health that we have in the literature are exclusively negative. Absent is the study of refugee health or of healthy refugees. Yet refugees present perhaps the maximum example of the human capacity to survive despite the greatest of losses and assaults on human identity and dignity. The concept of resilience has been examined among a variety of populations who have been exposed to major life stressors and could be of use in the study of healthy refugees. Resilience refers to social competence or other types of functional adequacy despite losses and stressors [92]. It may involve “the evaluative awareness of a difficult reality combined with a commitment to struggle, to conquer the obstacle, and to achieve one’s goals despite the negative circumstances to which one has been exposed, which were and remain evocative of sadness” [93]. A recent study of Vietnam War veterans with and without PTSD found that among those without PTSD, veterans with high combat experience evidenced less ‘neuroticism’ than did those with low combat experience, suggesting extraordinary

New paradigms for refugee health problems resilience among the former [94]. Similar studies are indicated with refugees. Shift of focus from refugee pathology to refugee health can provide exits from the reductionism of medicine and from the medicalization of problems of living in society. Recent qualitative research has shown that what medicine would declare disease may represent transition to a healthier ‘assumptive world.’ Muecke [95], for example, reported that temporary workplace absenteeism was associated with a Lao community’s reformulation of their identity to one that legitimated their leaving Laos and confirmed their ethnic identity in urban United States, thereby enhancing the health of the group both as a community and as individuals. Thompson [96] examined symbolic traditions that resettled Cambodian women brought with them to the United States as a means of reconfirming with them their own images and stories of women’s strength and resistance to oppression. These examples validate Lock’s [97] argument that limiting the significance of ethnic identity to a mere demographic characteristic reduces the identity to stereotype and obscures the local meaning of health from view. Issues pertaining to the understanding of refugees in resettlement The issues identified in this section derive from the assumption that a fundamental limitation to our understanding of refugee health is that the positivist paradigm of medicine has shaped most of our research and therapeutics. Another paradigm that is primarily concerned with refugees as extraordinarily resilient human beings is also indicated. 1. Our medical and economic paradigms for understanding resettled refugees have focused on the effects of change on them, on curing their medical problems and on training them to be economically self-supporting in new environments. These concerns have eclipsed attention to their capacity to change and to the meanings of change to them. Because refugees’ experiences with change approach the extreme among human groups, research with resettled refugees could clarify the processes and meanings of human change. 2. Participatory research is necessary to help reduce the power differentials between researchers and refugees that silence the authentic voices of refugees. Construing refugee ‘patients’ and research ‘subjects’ as resilient and as mutual participants could allow them latitude to reformulate their assumptive worlds as they need, and could inform health care practice and research with the unconventional perspectives needed to alleviate suffering among refugees. REFERENCES 1.

For example, the J. Refugee Stud. published since 1988, and Refugee Abstr. published since 1981. 2. In 1989, Western countries accepted some 931,000 refugees for permanent resettlement; this number included 720,000 ethnic Germans who resettled in the

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former Federal Republic of Germany after the Berlin Wall came down. Even so, resettlement in a Western country represents only 5.6% of the almost 17 million international refugees and new asylum seekers who required international assistance and/or protection in 1989. Source: World Refugee Statistics. World Refugee Survey-1991, VP. 32-36. U.S. Committee for Refugees, American Council for Nationalities Service, Washington, DC, 199 1. 3. According to the United Nations 1967 Protocol Relating to the Status of Refugees, which has 104 country signatories, a refugee is a person who is outside the country of her/his nationality (or habitual residence) and unable or unwilling to return to it or to its protection because of actual or threatened persecution on accent of race, religion, nationality, membership in a particular social group, or political opinion. 4. The ideological and military power of national governments that systematically displace their citizens are often dependent upon the political, economic and material support of other governments. For example: Pol Pot’s Kampuchea sustained by the People’s Republic of China, and the government of El Salvador sustained by the United States. 5. Clark L. Internal refugees-The hidden half. World Refugee Survey-I988 in Review, pp. 18-24. U.S. Committee for Refugees, American Council for Nationalities Service, Washington, DC, 1989. 6. World Refugee Survey-1990 in Review, p. 34. U.S. Committee for Refugees, American Council for Nationalities Service, 199 1. 7. For example, the World Refugee Survey-1991 estimates one million internally displaced in Ethiopia (p. 34), yet NGO staff in Addis Ababa and along the Sudanese border estimate there are 9.6 million disnlaced persons inside Ethiopia. Personal communication, Howard Berry, Director, World Concern, Seattle, Washington, 1992. 8. Frelick B. Refugees: a barometer of genocide. World Refugee Survey-1988 in Review, pp. 13-17. U.S. Committee for Refugees, American Council for Nationalities Service, 1989. 9. Kiernan B. Orphans of genocide: The Cham Muslims of Kampuchea under Pol Pot. Bull. Concerned Asian Scholars 20, (4), 2-33, 1988. 10. Van den Berghe P. L. State Violence and Ethnicity. University Press of Colorado, Niwot, CO, 1990. 11. Pizzarello L. D. Aae soecific xeroohthalmia rates amona displaced Ethiopians.’ Arch. Dis.’ Child. 61, 110&l 103: 1986. 12. Harrell-Bond B. E. Imposing Aid: Emergency Assistance to Refugees. Oxford University Press, Oxford, 1985. 13. Simmonds S., Vaughan P. and Gunn S. W. Refugee Community Health Care. Oxford University Press, New York, 1983. 14. de Brun S. and Elling R. H. Cuba and the Philippines: Contrasting cases in world-system analysis. Inr I. Hlrh Serv. 17, 681-701, 1987. 15. Gilpin M. Cuba: Update--Cuba: On the road to a family medicine nation. J. Publ. Hlrh Policy 12, 83-103, 1991. 16. Swanson J. M. Health-care delivery in Cuba: Nursing’s role in achievement of the goal of “Health for All.” Int. J. Nurs. Stud. 25, 11-21, 1988. 17. Wilson A. Health. Women and the Eriirean Revolution: The Challenge Road. pp. 139-149. The Red Sea Press, Trenton, NJ, 1991. 18. Sabo L. E. and Kibirige J. S. Political violence. and Eritrean health care. Sot. Sci. Med. 28, 677-684, 1989. 19. Cliff J. and Noormahomed A. R. Health as a target: South Africa’s destabilization of Mozambique. Sot. Sci. Med. 27, 717-722, 1988.

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New paradigms for refugee health problems.

Two paradigms that have shaped our understanding of refugee health are identified: the objectification of refugees as a political class of excess peop...
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